'Dual-eligibles' (Medicare/Medicaid) can join pilot program in Feb. 2014

This week, the Centers for Medicare & Medicaid Services (CMS) announced that Virginia will partner with CMS to test a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience.

There are approximately 78,500 "dual eligibles" in Virginia, more than 18,000 of them in Tidewater, which will be among the first regions to be phased in. Starting in Feb. 2014, beneficiaries will be able to opt in to the program. Beneficiaries will also be able to opt out of the Demonstration or select an alternative MMP plan at any time.

In Tidewater, "dual eligibles" divide almost evenly between those in nursing facilities and those with an ECDC waiver; more than 12,500 are in the community without a waiver.

Under the Demonstration, Virginia and CMS will contract with Medicare-Medicaid Plans to coordinate the delivery of and be accountable for covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees.

Many Medicare-Medicaid enrollees suffer from multiple or severe chronic conditions and could benefit from better care coordination and management of health and long-term supports and services, according to CMS.

Some other states started participation in this model in 2011. Under the demonstration, CMS will evaluate the effectiveness of two models:

Managed Fee-for-Service Model in which a state and CMS enter into an agreement by which the state would be eligible to benefit from savings resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid; and

Capitated Model in which a state and CMS contract with health plans or other qualified entities that receive a prospective, blended payment to provide enrolled Medicare-Medicaid enrollees with coordinated care.

Virginia is the sixth state to enter a Memorandum of Understanding (MOU) with CMS to participate in the Demonstration.

The Virginia DemonstrationVirginia has long supported the Program of All-Inclusive Care for the Elderly (PACE), a capitated model, and Virginia is now expanding and improving upon these efforts to reach the broader population of Medicare-Medicaid enrollees that have had limited access to the benefits of care coordination to date.

Under the Demonstration, MMPs will be responsible for providing a comprehensive assessment of Medicare-Medicaid enrollees’ medical, behavioral health, long-term services and supports, functional, and social needs. Medicare-Medicaid enrollees and their caregivers will work with an interdisciplinary care team to develop person-centered, individualized care plans. The Demonstration is designed to offer opportunities for beneficiaries to self-direct services, be involved in care planning, and live independently in the community. ...

In addition, the Demonstration includes robust continuity of care requirements to ensure that beneficiaries can continue to see their current providers (including those at community health centers) during transitions into the Demonstration health plan.

Putting the Beneficiary FirstUnder the Demonstration, care coordination services will be available to all enrollees. MMPs will offer an interdisciplinary care team to ensure the integration of the member’s medical, behavioral health, long term services and supports, and social needs. The team will be person-centered: built on the enrollee’s specific preferences and needs.

Eligible beneficiaries who have not made a choice to opt in or out will be assigned to an MMP through a process that will match beneficiaries with the most appropriate plan for the individual’s health needs.